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The Stabilizing System of the Spine. Part I. Function, Dysfunction, Adaptation, and Enhancement
Manohar M. Panjabi
Department of Orthopaedics and Rehabilitation, Yale University School of Medicine, New Haven, Connecticw U.S.A.
Summary: Presented here is the conceptual basis for the assertion that the spinal stabilizing system consists ofthree subsystems. The vertebrae, discs, and ligaments constitute the passive subsystem. All muscles and tendons surrounding the spinal column that can apply forces to the spinal column constitute the active subsystem. The nerves and central nervous system comprise the neural subsystem, which determines the requirements for spinal stability by monitoring the various transducer signals, and directs the active subsystem to provide the needed stability. A dysfunction of a component of any one of the subsystems may lead to one or more of the following three possibilities: (a) an immediate response from other subsystems to successfully compensate, (b) a long-term adaptation response of one or more subsystems, and (c) an injury to one or more components of any subsystem. It is conceptualized that the first response results in normal function, the second results in normal function but with an altered spinal stabilizing system, and the third leads to overall system dysfunction, producing, for example, low back pain. In situations where additional loads or complex postures are anticipated, the neural control unit may alter the muscle recruitment strategy, with the temporary goal of enhancing the spine stability beyond the normal requirements. Key
Words: Spine stabilizing system-Spinal instability-Lumbar spine-Muscle
function-Low back pain.
As co-editor of Journal of Spinal Disorders, I am delighted to ofer to our readership this elegant hypothesis ofered by Panjabi. I encourage all ofyou to read both the compelling article by Panjabi, and the articulate commentary by Krag. Such thoughtful discourse will do much to enhance our understanding of spinal stability. In addition, I hope that the areas of controversy will provide the impetusforfurther investigations. Manuscripts such as these will be published on a periodic basis to offer the concepts, thoughts, and ideas of recognized authorities who are involved in studying spinal disorders.
Dan M. Spengler, M. D.
of low back pain (38), it is not surprising that many of the present treatments are relatively ineffective. Spinal instability is considered to be one of the important causes oflow back pain but is poorly defined
and not well understood (24). The basic concept of spinal instability is that abnormally large intervertebral motions cause either compression and/or stretching of the inflamed neural elements or abnormal deformations of ligaments, joint capsules, annular fibers, and end-plates, which are known to have significant density ofnocioceptors (41). In both situations, the abnormally large intervertebral motions may produce pain sensation. Knutsson (19) was probably the first to propose a
Low back pain is a well-recognized problem of the lation and resulting in substantial social loss (2,I I,23, 37). Because the etiology is unknown for most types
Address correspondence and reprint requests to Dr. M. M. Panjabi, Department ofOrthopaedics and Rehabilitation, Yale University School of Medicine, New Haven, CT 06510, U.S.A.
dysfunction. there are contradictory observations and hypotheses. 5. The three subsystems work togethil to achieve the goal as described in subsequent paragraphs and schematically shown in Fig. the components of the spinal stabilizing system are presented. In addition to the abnormal magnitudes (larger or smaller than normal). and joint capsules. spinal ligaments. Both hypo. and. and lateral bending have been suggested as signs ofspinal instabil- 1. The active musculoskeletal subsystem consists of the muscles and tendons surrounding the spinal column. (8) in low back pain patients with degenerative changes in the spine. active spinal muscles. located in ligaments.and hypermobility of the spine' as measured by the range of motion without regard to the direction of vertebral fiiovements. A better understanding of the workings of the spinal stabilizing system may also be useful in this respect. 1). (34) and Dvorak et al. First. Pearcy et al. it is of fundamental significance to the human body. Other studies have found a mixed set of results. This kinematic parameter is hypothesized to J Spinal Disord Vol. and adaptation/enhancement functions. DESCRIPTION The basic biomechanical functions of the spinal system are (a) to allow movements between body parts. new types of motion information must be obtained. (36). and static and dynamic loads. In this part of a two-part article. both in an in vitro model (35) and in low back pain patients (7). Seligman et al. the motion quality is another parameter. suggested that the increased length of the path of the centers of rotation during flexion/extension may be a predictor of spinal instability. therefore. extension. sented. Decreased motion was found by Pearcy et al. (8) reported increased motion in younger athletic patients with back pain. tendons. The spinal stability system consists of three subsystems: passive spinal column. are functionally Normal Function of the Spinal Stabilizing System The normal function of the stabilizing system is to provide sufficient stability to the spine to match the instantaneously varying stability demands due to changes in spinal posture. including the normal function. PANJABI mechanical parameter as an indicator of spinal insta- bility: the retrodisplacement (anterior to posterior translation) of a vertebra observed on lateral radiographs while flexing the spine from the extended posi- tion. ln the same study. (b) to carry loads. there have been several attempts made in the past to relate the clinical problem oflow back pain to an abnormality in intervertebral motion.20. driven from the hypotheses. active. new hypotheses must be developed. There is some recent evidence to support these observations of increased motion being related to low back problems ( 12.384 M. as well as the passive mechanical properties of the muscles. intervertebral discs. Although some useful information has been gathered. 4' 1992 . the concept ofneutral zone is pre- muscles. and ity. M. be a functional measure of the spinal stabilizing system. To make progress on this clinically important problem of spinal instability. dysfunction. alinterdependent. also using the concept of the center of rotation and experimental results of an in vitro study. and the neural control centers' These passive. Dvorak et al. Abnormally large dispersion of the centers of rotation during flexion. Thus. and neural control subsystems. Mechanical stability of the spine is necessary to perform these functions and. The passive musculoskeletal subsystem includes vertebrae. No. In the second part. though conceptually separate. Similar observations concerning the coupled torques also have been made (32). the purpose is to present a group ofconcepts concerning the stabilizing system of the spine. followed by descriptions of its normal function. 2. and (c) to protect the spinal cord and nerve roots (39). FlG. facet articulations. and enhanced function. There may also be motion quality abnormalities. (33) found coupled axial rotations and lateral bending motions during flexion/extension in low back pain patients as compared with the control group.40). have been proposed by another hypothesis ofspinal instability (18). The spinal stabilizing system is conceptualized as consisting of three subsystems (Fig. and neural control unit. The neural andfeed' back subsysten consists of the various force and motion transducers.
and attempts to compensate by initiating appropriate changes in the active subsys- The Passive ( Ligamentous) Subsystem Components of the passive subsystem. degeneration. Consequently. which may develop suddenly or gradually. muscle spasm. but it is dynamically active in monitoring the transducer signals.4. and muscle fatigue. The information from the (1) Passive Subsystem sets up specific (2) spinal stability requirements. determines specific requirements for spinal stability. The requirements for the spinal stability and. degeneration and/or disease may decrease the (2) passive stability and/or (3) active stability. 1992 .SPINE STABILIZING SYSTEM I 38s tension is measured and adjusted until the required stability is achieved. Therefore. the individual muscle tensions. It is toward the ends of the ranges of motion that the ligaments develop reactive forces that resist spinal motion. requirements for (3) individual muscle tensions are determined by the neuralcontrol unit. and causes the active subsystem to achieve the stability goal. there may be a functional reserve that can be called on to enhance spinal stability beyond the normal level. lf these changes cannot adequately compensate for the stability loss. 2. (e. Degradation of the spinal system may be due to injury.3. The magnitude of the force generated in each muscle is measured by the force transducers built into the tendons of the muscles. the subsequent consequences may be deleterious to the individual components ofthe spinal system (e. ligaments) do not provide any significant stability to the spine in the vicinity of the neutral position. In addition. similar to those proposed for the knee ligaments (3). The Active (Musculotendenous) Subsystem tem. FlG. the consequences may be chronic dysfunction and pain.g.g. injury. The neural control subsystem perceives these deficiencies. under circumstances of unusually demanding loading conditions. The Neural Control Subsystem The neural subsystem receives information from the various transducers. and therefore are part of the neural control subsystem. No. (4) The neural control unit attempts to remedy the stability loss by increasing the stabilizing function of the remaining spinal components: (5) passive and (6) active. 5. are dependent on dynamic posture. a (8) chronic dysfunction or pain may develop. This may lead to (7) accelerated degeneration. Adaptation and Enhancement of the Stabilizing Capacity This ability of the spinal system to respond to dysfunction is one manifestation of its adaptability. Although the necessary stability of the spine overall may be reestablished. Individual muscle Dysfunction of the spinal stability system. this subsystem is passive only in the sense that it by itselfdoes not generate or produce spinal motions. Feedback is provided by the (5) force monitors by comparing the (6) "achieved" and (3) "required" individual muscle tensions. therefore.. 3). (1) lnlury.. and fatigue). Over time. this aspect of the tendons is part of the neural control subsystem. The muscles and tendons of the active subsystem are the means through which the spinal system generates forces and provides the required stability to the spine. vari- ation of lever arms and inertial loads of different masses. that is. Dysfunction of the Spinal Stabilizing System FlG. accelerated degeneration of the various components of the spinal column. Thus. J Spinal Disord Vol. The passive components probably function in the vicinity ofthe neutral position as transducers (signal-producing devices) for measuring vertebral positions and motions. The message is sent to the (4) force generators. abnormal muscle loading. and/or disease of any one of the subsystems (Fig. and external loads. Functioning of the spinal stability system.
development of tears and fissures in the annulus. the so-called critical load of the spinal column' has been determined by in vitro experiments (6. This is based on experimental observations from which we know that all passive spines (cadaveric spine specimens devoid of musculature) exhibit measurable neutral zones. Thus. This leads to the hypothesis that the deformations in deterioration ofits ability to receive and/or carry out the neural commands. within the physiological ranges of spinal movements and against normal spinal loads. the deformations of the ligaments are large (3 1). within certain limits. the normal function of the stabilizing system of the spine involves monitoring tissue deformations and selecting appropriate muscles and adjusting individual muscle tensions to accommodate changes in physiological postures. the deformations of soft tissues are capable of providing a comprehensive set of signals from which stability requirements may be determined. A structure may also be weakened by degeneration or disease. respectively. about two to three times body weight (140-210 kg). and extrusion of the disc material into the vertebral bodies. Normal Function The load-carrying capacity of the passive subsystem. M. This large load-carrying capacity is achieved by the participation of well-coordinated muscles surrounding the spinal column' Thus. The normal loads on the spine provided by body mass alone in the standing Any one or more of the subsystems may not function appropriately. to provide accurate feedback of muscle tension information to the neural control the ligaments provide a more useful feedback signal than do the forces for monitoring the requirements for spinal stability. affecting the overall stability ofthe spinal system. the system may be enhanced beyond the normal. then acute or chronic problems may arise. and spinal loads. although the neutral zones are generally The dysfunction of the passive subsystem may be caused by mechanical injury such as overstretching of the ligaments. or injury. As a result. They found that the spinal column specimens buckled (became mechanically unstable) at a load of 20 N (2 kg) and 90 N (9 kg). 5.21). On the other hand. or to produce coordinated and adequate muscle tensions. the three subsystems are highly coordinated and optimized. 1992 . degeneration. developed. disease. Because the ligaments deform under load. How does the spinal stabilizing system determine the forces needed from the muscles? What is the initiating signal coming from the transducers located in the passive subsystem? Probably it is the ligament deformation (strain) and not the force (stress). Thus. Degeneration of the disc is known to weaken it in resisting torsional loads (10)' There is some evidence to suggest that other multidirectional physical properties ofthe spine are also altered by degeneration (29).28). In certain situations. DYsfunction beyond these limits. The main thrust of the proposed biomechanical concept of the stabilizing system of the spine is that there are two musculoskeletal components and one neural component. The injury may result from overloading of a normal structure or normal loading of a weakened structure. for the Tl-sacrum and L5-sacrum specimens. The Active SubsYstem larger after degeneration (31) and injury Q7. The Passive SubsYstem position (25) are many times larger. This may require compensatory changes in the active subsystem. If the dysfunction is In addition to the feedback provided by the ligament deformation. Throughout the neutral zone. the importance of the active subsystem (the muscles) in providing the required stability is well established. Even bigger loads may be expected under dynamic situations or from carrying external loads. the reactive forces are small.386 M. spinal movements. 4. The stability requirements are also dependent on the loads carried by the spine. In general. and optimized to achieve this goal. may be provided by the system. if needed. No. throughout the neutral The active musculoskeletal subsystem may develop zone. such deformation may result from disuse. The spinal stabilizing system has been designed. Under normal circumstances. Compensation for dysfunction of the system. instantaneous muscle tension is probably monitored by the muscle spindles and tendon organs (9) and adjusted by the neural control unit in accordance with the requirements for stability. PANJABI DISCUSSION spinal loads. all these factors decrease the load-bearing and stabilizing capacity of the passive subsystem. development of microfractures in the endplates. the stabilizing capacity of the spinal system may be decreased' This may compromise the capability of the system to J Spinal Disord Vol. they can sense the unit.
the passive subsystem may be attempting to compensate for the decreased stabilizing ability of the active subsystem.. In the latter study. The Neural Subsystem Dysfunction of the neural subsystem can also develop.g. By using the contralateral knee as the control. One may also expect that an awkward maneuver that is repeated The muscular strength decreases in the later years oflife. To achieve the required stability at every instance of time. the neural subsystem has the enormously complex task of continuously and simultaneously monitoring and adjusting the forces in each ofthe muscles surrounding the spinal column. The two phenomena may be related. One may speculate that the control of the spinal stabilizing system was permanently altered in the patients examined in both ofthese studies.. The Passive Subsystem ciation of the complexity of the task may be obtained by watching a sophisticated robot trying to walk a short distance. No. facet hypertrophy (10. Giove et al. but may further potentiate an injury. This may happen either due to the faulty information transmitted from the spinal system transducers or due to the fault ofthe control unit itself.g. requiring additional considerations for masses.18).. staggeringly. possibly.. in work environment) would in- to occur. Hypertrophy of the involved side was found in patients who had adopted best after the injury Q2). when the synchronizing capability of the neural control subsystem may be extended to its maximum. In addition to damagingthe active subsystem. A neural control dysfunction may become chronic. and twisting).4. This may be explained on the basis ofenhanced stability ofthe spinal system in the form of increased capacity to generate muscle tension. state-of-the-art computers. had greater body sway compared with the normal subjects performing the same task. It has also been observed that the spinal column stiffness increases in later years of life due to osteophyte formation and.SPINE STABILIZING SYSTEM both provide compensatory help to the passive subsystem when needed. The task is made much more complex if the posture and/or loads change dy- Adaptation and Enhancement namically. therapeutic intervention in the form of surgical fusion and external bracing may be used as treatments designed to enhance the spinal stability. The robot walks slowly. while picking up a piece of paper from the floor).g. I 387 tion in complex spinal motions involving lifting and twisting at the workplace.26). In another knee study. and to withstand unexpected dynamic or abnormally large external loads. a few clinical studies have documented the role of muscles in anterior cruciate ligament (ACl)-deficient knees. Instantaneous decisions must be made to redistribute the muscle tensions. Kelsey et al. Often such an incident may happen while performing a complex maneuver (e. the patients exhibited greater body sway after initiation of claudication.g.. One example of the kind of error that might occur is that one or more muscles may fire in a manner that is undesirable: too small or too large force and/or too early or too late firing. combined flexing. that is. 1992 . In the former study. bending. Theoretical models of spinal stability have predicted such an effect (i. increased spinal stability due to increased muscle tension) (6. In case the body's own adaptive responses are not enough.15. Involvement of a heavy external load in such a case is not a requirement for producing muscle injury and pain. (13) found increased value of the ratio of hamstring strength to quadricep strength to be many times (e. despite being controlled by high-performance. and will easily topple if subjected to a sudden external load. inertias. a single large overload has been shown experimentally to produce disc herniation ( l). This has been observed in studies conducted on patients with spinal stenosis ( 14) and low back problems (a). muscle force errors might lead to overload of a passive structure (e. (17) have documented increased risk for disc herniacrease the chance for an error J Spinal Disord Vol. if there is a change in the posture and/or the external loads. resulting in soft tissue injury and pain. when challenged with the task of standing on an unbalanced platform with eyes closed. and accelerations involved. With the spine in an awkward posture. with aging. The Active Subsystem A general increased muscle tone by training has been shown to decrease the risk for development of low back problems (5). the low back patients. Such an error may cause excessive muscle tension. This may explain some of the instances of acute low back pain initiations where negligible or maryinal loads are involved (e. disc).e. 5. An appre- Either chronic dysfunction of components of any of the subsystems or increased functional demands on them may lead to adaptive changes.
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